Annals for Hospitalists - December 2022
Authors: David H. Wesorick
Journal: Annals of Internal Medicine (2022)

Web ExclusivesDecember 2022Annals for Hospitalists - December 2022FREEDavid H. Wesorick, MDDavid H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202212200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesThe Future of Hospital-at-Home Care—Soumya Rangarajan, MD, MPP, and Grace Jenq, MDAlthough popular in Australia and the United Kingdom, hospital-at-home programs have only recently gained wide acceptance in the United States. Our authors explain the reasons for recent growth and implications for the future.Highlights of Recent Articles From Annals of Internal MedicineEffectiveness of mRNA COVID-19 Vaccine Boosters Against Infection, Hospitalization, and Death: A Target Trial Emulation in the Omicron (B.1.1.529) Variant EraAnn Intern Med. 2022;175:1693-1706. Published 11 October 2022. doi:10.7326/M22-1856This retrospective cohort study used U.S. Department of Veterans Affairs data in a target trial emulation study to evaluate booster efficacy in previously vaccinated patients. Patients either received a messenger RNA (mRNA) COVID-19 booster or no booster. Each group included 490 838 matched patients, with mean follow-up of 79.8 days. Booster efficacy was 42.3% for preventing SARS-CoV-2 infection, 53.3% for preventing hospitalization, and 79.1% for preventing death.Key points for hospitalists include:This study confirms that, even during the Omicron era, a booster dose of an mRNA COVID-19 vaccine remains moderately effective for preventing infection and hospitalization and highly effective for preventing death.Vaccine booster efficacy was highest for patients with more comorbidities and with longer durations between initial vaccination and administration of the booster.Medical Masks Versus N95 Respirators for Preventing COVID-19 Among Health Care Workers: A Randomized TrialAnn Intern Med. 2022;175:1629-1638. Published 29 November 2022. doi:10.7326/M22-1966This multinational, noninferiority trial randomly assigned 1009 unvaccinated health care workers to either standard medical masks or fit-tested N95 respirators when caring for patients with proven or suspected COVID-19 for 10 weeks during the period of May 2020 to March 2022. Medical mask use resulted in a hazard ratio for confirmed COVID-19 of 1.14 (95% CI, 0.77 to 1.69), showing noninferiority (defined as a lack of doubling of the hazard ratio). There was significant heterogeneity in the rate of COVID-19 and the hazard ratios among the different countries.Key points for hospitalists include:In this study, the use of medical masks, when providing direct care for patients with known or suspected COVID-19, was noninferior to the use of N95 respirators for preventing COVID-19 in hospital employees. (The noninferiority margin designated by this study was a doubling of the hazard ratio of contracting COVID-19.)An editorialist notes that the noninferiority margin used in this trial may be unacceptably large and that these results should not be interpreted as showing that these masks are equally protective against COVID-19. In fact, these results are consistent with up to a 70% relative risk increase of infection with the use of standard medical masks.Retiring the “Against Medical Advice” DischargeAnn Intern Med. 2022;175:1761–1762. Published 29 November 2022. doi:10.7326/M22-2964In this opinion article, the authors suggest replacing the commonly used discharge phrase “against medical advice (AMA)” with the less antagonistic “before medically advised (BMA).” They note that the AMA designation emphasizes that the patient is acting against the provider's advice, without considering the patient's perspective. On the other hand, the BMA designation raises curiosity about why the patient is making this decision and what might be done to avert the early discharge or make it safer.Key points for hospitalists include:The authors highlight that patients often leave AMA for tangible, potentially discoverable reasons (for example, undertreated withdrawal symptoms and pain, stigma and discrimination, inability to smoke, reminders of past incarcerations, and so forth) and that it requires a patient-centered, collaborative approach to understand those reasons and intervene appropriately.Against medical advice discharges are associated with increased 30-day readmission rates and postdischarge mortality. Therefore, it makes sense to reduce the frequency of these discharges by striving to meet patients' needs in the hospital.For patients who choose to leave BMA, the discharge plan should still maximize the patient's health by providing appropriate prescriptions and follow-up appointments.The Latest Highlights From Journal ClubDo fever reduction strategies improve outcomes in hospitalized patients?In hospitalized adults with fever, fever therapy does not reduce mortality or serious adverse eventsAnn Intern Med. 2022;175:JC127. doi:10.7326/J22-0081This meta-analysis of 16 randomized controlled trials (n = 2415) showed no reduction in mortality or serious adverse events related to the use of fever reduction strategies, which included antipyretic medications or physical cooling strategies.Do antisecretory drugs reduce risk for upper gastrointestinal (GI) bleeding in patients treated with oral anticoagulants?In adults using oral anticoagulants, PPI use may be associated with lower risk for upper GI bleedingAnn Intern Med. 2022;175:JC129. doi:10.7326/J22-0084This meta-analysis of mostly observational studies of patients receiving oral anticoagulants showed that proton-pump inhibitor (PPI) use is associated with a significantly lower rate of upper GI bleeding, and the magnitude of the benefit seems to depend on the underlying bleeding risk.What are the benefits and risks of the different anticoagulant medications used for venous thromboembolism (VTE) prophylaxis in acutely ill inpatients?In acutely ill inpatients, benefits and harms of anticoagulants for VTE prophylaxis were assessedAnn Intern Med. 2022;175:JC128. doi:10.7326/J22-0089This network meta-analysis of 44 randomized controlled trials estimated the risks and benefits of several drug classes used for VTE prophylaxis and found that none of them reduced mortality compared with placebo. Low-molecular-weight heparin was most efficacious at reducing symptomatic VTE events, and intermediate-dose unfractionated heparin was associated with the highest risk for major bleeding.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Disclosures:Author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - The Future of Hospital-at-Home Care Soumya Rangarajan and Grace Jenq Metrics Current IssueDecember 2022Volume 175, Issue 12Page: HO12 ePublished: 20 December 2022 Issue Published: December 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...